Surgery & Anesthesia Release
Client Information
Patient Information
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I authorize Petaluma Equine PC to anesthetize and perform the following surgery/procedure 

as explained to me by Dr. Sakai.

on the above patient.  I have been informed of and understand the inherent risk of anesthetizing and recovering horses from general anesthesia.  Including but not limited to; anaphylactic shock, cardiac arrhythmia, adverse drug reactions, muscle damage, nerve damage, fracture, catastrophic injury, and death.

 

I am responsible for the above horse and have the authority to grant consent to the hospitalization, anesthesia, surgery and/or related procedures.  I have been encouraged to discuss any concerns I have about these risks with my veterinarian before the procedure(s) are initiated.  My signature on this consent form indicates that my questions have been answered to my satisfaction.  I acknowledge the aforementioned risks and understand the veterinarians and hospital staff will take the necessary steps to minimize them.  I also acknowledge that no warranty or guarantee has been given to me as to the results or cure afforded by the procedures to be performed. 

 

In the event of surgical or medical complications during the procedure, I authorize Petaluma Equine PC to take the necessary diagnostic, surgical, and medical steps to ensure the patient’s well-being as directed by a veterinarian.  I will be available by phone during the procedure should the need arise to be contacted.   

 

I have read and fully understand this anesthesia and surgery authorization form and I WILL NOT HOLD PETALUMA EQUINE, PC OR THEIR AFFILIATES, EMPLOYEES OR VETERINARIANS LIABLE FOR ANY DAMAGES OR COMPLICATIONS THAT MAY ARISE FROM THESE PROCEDURES. 

Your Signature

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Contact

(707) 721-4402

Address

911 Mustang Court

Petaluma, CA 94954

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